Sclerotherapy for varicose vein has longer history compared to other treatment options, is indicated for various type of varicose veins, and low cost, repeatable treatment without complicated medical equipment. Sclerotherapy is often performed with additional treatments for better outcome. The optimal form of sclerosants (liquid or foam) depends on the type of varicose veins. The usefulness of sclerotherapy should be evaluated from not only anatomical vein occlusion but also costs and patients QOL although the recanalization is not rare after sclerotherapy. The opportunity of performing sclerotherapy as main procedures for saphenous varicose veins decreased because catheter endovenous ablation is preferred for interruption of saphenous vein reflux. However, sclerotherapy is applied for residual varicose veins, recurrent varicose veins and special cases which is hard to be applied catheter endovenous ablation. Therefore, physicians perform the treatment for varicose veins should obtain the knowledge and techniques of sclerotherapy.

This study aimed to investigate the efficacy of reduction treatment combined with lymphaticovenous anastomosis (LVA) for lower extremity lymphedema. The present study included one hundred and eight patients with lower extremity lymphedema who underwent LVA between November 2009 and July 2020. The patient cohort was divided into two groups depending on whether perioperative reduction treatment, namely compression therapy, exercise under compression, and manual lymph drainage, was implemented. The treatment group (n=58) took the additional treatment under the support of a lymphedema therapist during their seven days of postoperative hospitalization. Contrarily, the control group (n=50) had no other treatment during the hospitalization after LVA surgery. We compared the postoperative volume reduction between the two groups. The treatment group showed a tendency of higher volume reduction than the control group. This study suggested that patients would benefit from the reduction treatment in the early postoperative period efficiently and effectively because of increased lymph drainage capacity after LVA. Moreover, the environment where they can devote themselves to the reduction treatment during postoperative hospitalization could maximize the treatment outcome.

We report the treatment results of foam sclerotherapy alone with polidocanol without ligation for saphenous varicose veins performed at our hospital from 2003 to 2016. The main cases were the patients who did not wish to undergo surgery even if it was considered to be indicated for stripping or ablation. The number of cases was 296 cases, 383 limbs (338 great saphenous veins, 45 small saphenous veins). Surgery was performed later in 28 limbs (7.3%) (4 stripping, 19 EVLA, and 5 RFA) due to recurrence. The period from initial sclerotherapy to revision surgery was one to ten years (median 6 years). Complications such as induration and pigmentation were often observed, however none were serious. Since the method is simple and inexpensive, it is considered that one of the options is to treat saphenous varicose veins with foam sclerothearapy alone at the first time if the patients accept the high recurrence rate.

The importance of ultrasonography for varicose vein treatment is evident. However, the technique proposed by the Japanese Society of Phlebology requires additional time for the examination. We review whether the presence of reflux can be evaluated from the great saphenous vein (GSV) diameter. We measured reflux and GSV diameter near the sapheno-femoral junction and the center of the thigh. Moreover, we examined, the relationship of the GSV diameter to reflux, reflux diagnostic ability using the vein diameter, and reflux-negative diagnostic ability. When a symptom and reflux were observed, the GSV significantly dilated. Furthermore, GSV diameter was useful for reflux diagnosis, but without 100% sensitivity. Specificity was low when the sensitivity was set to 100% with reflux-negative diagnostic ability. We concluded that GSV diameter alone cannot determine the strategy for treatment of varicose veins, and reflux evaluation is necessary.

This article provides the early results of cyanoacrylate closure (CAC) for the treatment of incompetent great saphenous veins, which eliminates the need for tumescent anesthesia and thermal energy. This study investigated 32 consecutive patients (18 women; mean age, 64.2±1.6 years) with varicose veins between September 2020 and December 2021. We performed CAC therapy for truncal veins without stab avulsion phlebectomy, followed by sclerotherapy for incompetent tributary varicosities and the below-knee great saphenous vein (BKGSV) after 2–4 weeks. Sclerotherapy was performed before CAC therapy in 24 cases (75.0%). Residual reflux in the BKGSV after endovenous therapy persisted in 21 cases (65.6%), over a mean follow-up period of 8.6±0.9 months (range, 0–15 months). Hypersensitive reactions (HSR) were observed in four cases (12.5%). All cases of HSR occurred in patients whom in the great saphenous vein was at a depth <3 mm from the skin. We obtained good early results in terms of closure rates of incompetent great saphenous veins using CAC. These results show that CAC therapy was favorable, albeit with a short follow-up period without severe complications.

Case selection and initial results of cyanoacrylate closure (CAC) at one facility for saphenous veins of lower extremity varicose veins which has been generally covered by health insurance in Japan since 2020, are presented. Until December 2021, there were 206 consecutive cases (male 82, female 124, 70±12 years old), 277 limbs (CEAP classification, C2 171, C3 17, C4a 79, C4b 1, C5 3, C6 6), and 283 veins (GSV 238, SSV 45). For case selection, the characteristics of CAC and other treatments as well as the characteristics of each patient's lesion, were explained, and patients who wanted bilateral simultaneous treatment and those who needed treatment down to the middle calf were mainly treated; 283 of 549 (51.5%) saphenous veins treated during the same period were treated with CAC, and 93.3% of the patients visited the clinic up to 6 months after surgery. The condition of 17 of the 19 patients who did not visit the clinic was confirmed by telephone. Average treatment length was 40±13 cm in the GSV and 20±7 cm in the SSV. Mean diameter was 4.8±1.1 cm in the GSV (mean of the area parallel to the skin on the upper and lower 1/3 of the thigh) and 4.7±1.3 cm in the SSV (uniform area parallel to the skin on the upper 1/3 of the calf). Simultaneous treatments were varicectomy in 214/277 limbs (77%), form sclerotherapy (FS) of varices in 15/277 limbs (5%), severing of incompetent perforating veins (IPVs) in 5/277 limbs (2%), and FS of IPVs in 1/277 limbs (0.4%). The occlusion rate was 95.8% (GSV 96.2%, SSV 93.3%). Twelve recanalizations (GSV 9, SSV 3) were all partial, and four of them were re-treated. Grade 2 or higher deep venous junction thrombosis was observed in 2.1%. Foreign-derived inflammatory complications in 7.9%, of which 10 limbs were untreated and the remaining 12 limbs were treated and relieved by 5 weeks postoperatively. CAC is considered to be particularly useful in cases where the advantages of using a small amount of local anesthesia and not causing neuropathy can be of benefit.

As a less-invasive alternative to varicose vein surgery, we performed foam sclerotherapy for residual incompetent tributaries after truncal vein radio frequency ablation (RFA) without concomitant phlebectomy. This study investigated 298 consecutive patients (191 women; mean age, 67.3±0.7 years) with saphenous-type varicose veins between April 2018 and December 2021. We performed RFA alone in all patients for truncal veins without concomitant phlebectomy, afterwards sclerotherapy for incompetent tributary varicosities and the below-knee great saphenous vein (BK-GSV) between two and four weeks after RFA. No adverse events of nerve injury or severe thromboembolism occured after RFA. Reflux in the BK-GSV after RFA persisted in 186 (62.4%) cases. Foam sclerotherapy was performed once in 212 (71.1%) cases, two or more in 44 cases (14.8%). On the other hand, 42 cases (14.1%) did not require foam sclerotherapy. The mean follow-up period was 20.9±0.7 months (range, 0–44 months). Varicose veins recurred in four cases, due to development of anterior accessory saphenous vein incompetence and perforating vein incompetence in two cases, respectively, but no recurrence in the BK-GSV was observed. Post-EVTA treatment with foam sclerotherapy for incompetent tributaries varicosities and the BK-GSV appears as a safe, effective and less- invasive alternative to phlebectomy.

Cyanoacrylate (CA) embolization is the treatment to eliminate reflux due to venous valve insufficiency of truncal varicose veins. CA delivered into the vein, elicits a granulomatous foreign body reaction and a concomitant inflammatory vein wall reaction, leading to subsequent fibrotic degradation. Even though CA embolization does not require compression therapy, post-procedure phlebitis has been reported in about 10% of patients. In contrast, as we have continued post-operative compression therapy after CA embolization, the incidence of phlebitis was lower than that of other reports. Actual procedure was to put the compression pads (compression pressure about 50 mmHg) along the overlying skin on the embolized saphenous vein and to apply the elastic bandage. Next morning, the bandage and pads were removed and the elastic stockings should be worn during daytime for 4 weeks. During January to December 2021, the incidence of phlebitis was investigated in 115 patients (28 male, 87 female, mean age 67.5 years old), 141 legs (114 great saphenous, 27 small saphenous veins). Three cases (2.1%) had skin redness like allergic reaction over the treated saphenous veins. Thrombo-phlebitis has occurred in two cases (1.4%) of varices, at non-injected site of CA. In conclusion, the incidence of post-procedure phlebitis could be reduced by continuous post-operative compression therapy for CA embolization treatment of varicose veins.

Pelvic congestion syndrome presents chronic pelvic pain, atypical varicose veins, recurrent varicose veins or leg pain. The cause of these symptoms is reflux of the left ovarian vein. We report our experience in treating eight cases of pelvic congestion syndrome with reflux of the left ovarian vein. The patients were treated with EVLA and sclerotherapy for varicose veins in the lower limbs or perineal varices, and coil embolization of the left ovarian vein was performed in 7 cases. After coil embolization in 7 patients, 4 patients had residual or recurrent ovarian vein reflux. One of them underwent coil embolization of the left ovarian vein again due to recurrence of symptoms. All patients, including the one who underwent repeat embolization, had symptomatic relief. There were no complications or worsening of symptoms due to coil embolization. Coil embolization of the ovarian vein is effective in improving symptoms with few serious complications.

Recently, we are just wondering about that many residual or recurrent varicose veins are still left, even after the treatment of laser or radiofrequency ablation and glue embolization. The bottom cause of varicose vein is venous hypertension, so the fundamental treatment is compression therapy undoubtedly. I have been treating varicose veins depends on this basic thought and the essential points are described as follows. Compression therapy using suitable elastic stocking is required before sclerotherapy to avoid edema or swelling of the legs. The injection sites and volume of sclerosant could be reduced, as some varices would be diminished due to compression therapy. Preoperative compression could improve the circulation of the tissue, then the skin trouble due to sclerotherapy would be diminished. After the edema is relieved, subcutaneous varices could be seen clearly, as necessary, the vein viewing device are used. Sclerosant are prepared not all-foamed, but half foam with half liquid. The compression therapy after sclerotherapy is to put the urethane compression pads on the injection sites and to apply the elastic bandage. Next morning, the bandage and pads are removed and the elastic stockings should be worn during daytime for 4 weeks to obtain the excellent therapeutic effects.